1. Hossam hassan Department of Emergency Medicine
Acute Abdomen
Hossam hassan
Department of Emergency Medicine

2. Which one has the highest mortality rate ?
Ruptured AAA
Perforated peptic ulcer
Mesenteric ischemia
Bowel obstruction

3. Which one has the highest mortality rate ?
Ruptured AAA
Perforated peptic ulcer
Mesenteric ischemia
Bowel obstruction

4. Pain is out of proportion is a characteristic feature of:
Mesenteric ischemia
Ruptured AAA
Perforated peptic ulcer
Intestinal obstruction

5. Pain is out of proportion is a characteristic feature of:
Mesenteric ischemia
Ruptured AAA
Perforated peptic ulcer
Intestinal obstruction

6. Is the most common presenting surgical emergency
Is the most common presenting surgical emergency. It has been estimated that at least 50% of general surgical admissions are emergencies and 50% of them present with acute abdominal pain.

7. ‘Acute abdomen’ is a term used to encompass a spectrum of surgical, medical and gynecological conditions, ranging from the trivial to the life- threatening, which require hospital admission, investigation and treatment.

8. The acute abdomen may be defined generally as an intra-abdominal process causing severe pain requiring admission to hospital, and which has not been previously investigated or treated and may need surgical intervention.

9. The mortality rate varies with age, being the highest at the extremes of age.
The highest mortality rates are associated with laparotomy for un-resectable cancer, ruptured abdominal aortic aneurysm and perforated peptic ulcer.
Most common causes in any population will vary according to age, sex and race, as well as genetic and environmental factors.

10. Causes- Gastrointestinal- 1-Gut Acute appendicitis
Intestinal obstruction
Perforated peptic ulcer
Diverticulitis
Inflammatory bowel disease
2-Liver and biliary tract cholecystitis cholangitis Hepatitis 3-Pancreas Acute pancreatitis 4-Spleen Splenic infarct and spontaneous rupture

11. Causes- B. Urinary tract C. Vascular D. Abdominal wall conditions
Cystitis
Acute pyelonephritis
Ureteric colic
Acute retention
C. Vascular
Ruptured aortic aneurysm
Mesenteric embolus
Mesenteric venous thrombosis
Ischemic colitis
D. Abdominal wall conditions
Rectus sheath haematoma
E. Peritoneum
Primary peritonitis
Secondary peritonitis

12. Causes- F. Retroperitoneal Hemorrhage e.g anticoagulants
G. Gynecological
Torsion of ovarian cyst
Ruptured ovarian cyst
Fibroid denegeration
Ovarian infarction
Pelvic endometriosis
Endometriosis

13. Causes-
H. Extra-abdominal causes Lobar pneumonia MI Sickle cell crisis Uremia DKA Addison’s disease

14. Management
History
Physical examination
treatment

15. Characteristics of abdominal pain
Site
Time and mode of onset
Severity
Nature/Character
Progression
Radiation
Duration
Cessation
Exacerbating/relieving factors
Associated symptoms

17. Symptoms--Pain
Onset Sudden: perforation of bowel. Slow insidious onset: inflammation of visceral peritoneum Severity Patient asked to rate pain from 1-10 Ureteric colic is one of worst pains Character Aching-dull pain poorly localized Burning- peptic ulcer symptoms Stabbing-ureteric colic Gripping-smooth muscle spasm e.g. intestinal obstruction worse by movement .

18. Symptoms--Pain Progression -Constant e.g. peptic ulcer
-Colicky e.g. seconds(bowel), minutes(ureteric colic) or tens of minutes (gallbladder)
Radiation of the pain
Back: duodenal ulcer, pancreatitis, aortic aneurysm
Scapula: gall bladder
Sacroiliac region: ovary
Loin to groin: ureteric colic
Groin: testicular torsion

19. Cessation- Abrupt ending- colicky pains Resolving slowly-inflammatory pain, biliary pain Exacerbating/relieving factors- Movement/Rest-inflammatory conditions Food- peptic ulcers

20. History

21. History
Past history previous surgery trauma any medical diseases Drug history corticosteroid: mask pain anti-coagulant: intra-mural hematoma NSAIDS: gastritis, peptic ulcer Family history colon cancer IBD

22. Physical Examination -Patient is lying motionless General appearance
acute appendicitis, peritonitis
-Rolling in bed
ureteric colic, intestinal colic
-Bending forward
chronic pancreatitis

23. Physical Examination Vital signs Temp. General examination-
low grade: appendicitis, acute cholycystitis
high grade: abscess
General examination-
Conjuctival pallor
cyanosis
jaundice
Signs of dehydation
lymphadenopathy

24. Physical Examination -MI Cardio-pulmonary examination -basal pneumonia
-pleural effusion

25. Physical Examination Abdomen *Inspection *Palpation *Percussion
*Auscultation

26. Physical Examination
Inspection -movement with respiration -distension, peristalsis, mass, scars and any obvious cough impulse at hernia site Palpation *Superficial palpation -tenderness, rebound tenderness, guarding, rigidity, masses, hernial orifices *Deep palpation -organomegaly

27. Physical Examination -Silent abdomen: peritonitis Percussion
-Tympanic note: intestinal obstruction
-Dullness over bladder: acute retention
Auscultation
-Silent abdomen: peritonitis
-Increase bowel sound: intestinal obstruction

28. Investigation CBC Urea, electrolyte, creatinine, glucose LFT Lipase
Urinalysis
CXR
Abd.XR
CT SCAN
U/S
Angiography
Pregnancy test

29. Treatment 1. Relieve the pain 2. IV fluids and nasogastric suction
3. Antibiotics
4. Surgery if indicated

30. Case #1
24 yo healthy M with one day hx of abdominal pain. Pain was generalized at first, now worse in right lower abd & radiates to his right groin. He has vomited twice today. Denies any diarrhea, fevers, dysuria or other complaints. No appetite today.
PMHx: negative
PSurgHx: negative
Meds: none
Basic cases to go through the most common abd pain complaints we see in the ED

31. Physical exam:
T: 37.8, HR: 95, BP 118/76, R: 18, O2 sat: 100% room air
Uncomfortable appearing, slightly pale
Abdomen: soft, non-distended, tender to palpation in RLQ with mild guarding; hypoactive bowel sounds
Genital exam: normal
What is your differential diagnosis and what do you do next?

32. Appendicitis Classic presentation Periumbilical pain
Anorexia, nausea, vomiting
Pain localizes to RLQ
Occurs only in ½ to 2/3 of patients
26% of appendices are retrocecal and cause pain in the flank; 4% are in the RUQ
A pelvic appendix can cause suprapubic pain, dysuria
Males may have pain in the testicles

33. Urinalysis abnormal in 19-40%
CBC is not sensitive or specific
CT scan
Pericecal inflammation, abscess, fluid collection, localized fat stranding

34. Appendicitis: CT findings
Cecum
Abscess, fat
stranding

35. Appendicitis Diagnosis Treatment WBC Clinical appendicitis
Maybe appendicitis - CT scan
Not likely appendicitis – observe for 6-12 hours or re- examination in 12 hrs
Treatment
NPO
IVFs
Preoperative antibiotics – decrease the incidence of postoperative wound infections
Analgesia

36. Case #2
68 yo F with 2 days history of LLQ abd pain, diarrhea, fevers/chills, nausea; vomited once at home.
PMHx: HTN, diverticulosis
PSurgHx: negative
Meds: HCTZ

37. Case #2 Exam T: 37.6, HR: 100, BP: 145/90, R: 19, O2sat: 99% room air
Gen: uncomfortable appearing, slightly pale
CV/Pulmonary: normal heart and lung exam, no LE edema, normal pulses
Abd: soft, moderately TTP LLQ
Rectal: normal tone, occult blood neg brown stool
What is your differential diagnosis & what next?

38. Diverticulitis Risk factors Diverticula Increasing age
Clinical features
Steady, deep discomfort in LLQ
Change in bowel habits
Urinary symptoms
Tenesmus
Paralytic ileus
SBO
Physical Exam
Low-grade fever
Localized tenderness
Rebound and guarding
Left-sided pain on rectal exam
Occult blood
Peritoneal signs

39. Diverticulitis Diagnosis CT scan (IV and oral contrast)
Pericolic fat stranding
Diverticula
Thickened bowel wall
Peridiverticular abscess
Leukocytosis present in only 36% of patients

40. Treatment
Fluids
Correct electrolyte abnormalities
NPO
Abx: gentamicin AND metronidazole OR clindamycin OR levaquin/flagyl
For outpatients (non-toxic)
liquid diet x 48 hours
cipro and flagyl

41. Case #3
46 yo M with hx of alcohol abuse with 3 days of severe upper abd pain, vomiting, subjective fevers.
Med Hx: negative
Surg Hx: negative
Meds: none; Allergies: NKDA

42. Case #3 Exam
Vital signs: T: 37.4, HR: 115, BP: 98/65, R: 22, O2sat: 95% room air
General: ill-appearing, appears in pain
CV: tachycardic, normal heart sounds, pulses normal
Lungs: clear
Abdomen: mildly distended, moderately TTP epigastric, +voluntary guarding
Rectal: heme neg stool
What is your differential diagnosis & what next?

43. Pancreatitis Risk Factors Alcohol Gallstones Drugs
Amiodarone, antivirals, diuretics, NSAIDs
Severe hyperlipidemia
Idiopathic
Clinical Features
Epigastric pain
Radiates to back
Severe
N/V

44. Physical Findings
Low-grade fevers
Tachycardia, hypotension
Respiratory symptoms
Atelectasis
Pleural effusion
Peritonitis – a late finding
Ileus
Cullen sign*
Bluish discoloration around the umbilicus
Grey Turner sign*
Bluish discoloration of the flanks

45. Pancreatitis Diagnosis Lipase Elevated more than 2 times normal
Sensitivity and specificity >90%
Amylase
Nonspecific
CT scan
Insensitive in early or mild disease
NOT necessary to diagnose pancreatitis
Useful to evaluate for complications

46. Treatment
NPO
IV fluid resuscitation
NGT if severe, persistent nausea
No antibiotics unless severe disease
E coli, Klebsiella, enterococci, staphylococci, pseudomonas
Imipenem or cipro with metronidazole
Mild disease, tolerating oral fluids
Discharge on liquid diet
Follow up in hours
All others, admit

47. Case #4
72 yo M with hx of CAD on aspirin and Plavix with several days of dull upper abd pain and now with worsening pain “in entire abdomen” today. Some relief with food until today, now worse after eating lunch.
Med Hx: CAD, HTN, CHF
Surg Hx: appendectomy
Meds: Aspirin, Plavix, Metoprolol, Lasix
Social hx: smokes 1ppd, denies alcohol or drug use, lives alone

48. Case #4 Exam T: 37.1, HR: 70, BP: 90/45, R: 22, O2sat: 96% room air
General: elderly, thin male, ill-appearing
CV: normal
Lungs: clear
Abd: mildly distended and diffusely tender to palpation, +rebound and guarding
Rectal: blood-streaked heme + brown stool
What is your differential diagnosis & what next?

49. Peptic Ulcer Disease Risk Factors H. pylori NSAIDs Smoking Hereditary
Clinical Features
Burning epigastric pain
Sharp, dull, achy, or “empty” or “hungry” feeling
Relieved by milk, food, or antacids
Awakens the patient at night
Nausea, retrosternal pain and belching are NOT related to PUD
Physical Findings
Epigastric tenderness
Severe, generalized pain may indicate perforation with peritonitis
Occult or gross blood per rectum or NGT if bleeding

50. Peptic Ulcer Disease Diagnosis Rectal exam for occult blood CBC LFTs
Definitive diagnosis is by EGD or upper GI barium study
Treatment
Empiric treatment
Avoid tobacco, NSAIDs, aspirin
PPI or H2 blocker
Immediate referral to GI if:
>45 years
Weight loss
Long h/o symptoms
Anemia
Persistent anorexia or vomiting
GIB

51. Here is your patient’s x-ray….

52. Perforated Peptic Ulcer
Abrupt onset of severe epigastric pain followed by peritonitis
IV, oxygen, monitor
CBC, T&C, Lipase
Acute abdominal x-ray series
Lack of free air does NOT rule out perforation
Broad-spectrum antibiotics
Surgical consultation

53. Case #5
35 yo healthy F presented to ED c/o nausea and vomiting since yesterday along with generalized abdominal pain. No fevers/chills, +anorexia. Last stool 2 days ago.
Med Hx: negative
Surg Hx: s/p hysterectomy (for fibroids)
Social Hx: denies alcohol, tobacco or drug use

54. Case #5 Exam T: 36.9, HR: 100, BP: 130/85, R: 22, O2 sat: 97% room air
General: mildly obese female, vomiting
CV: normal
Lungs: clear
Abd: moderately distended, mild TTP diffusely, hypoactive bowel sounds, no rebound or guarding
What is your differential and what next?

55. Upright abd x-ray

56. Bowel Obstruction Physical Findings Mechanical or nonmechanical causes
1 - Adhesions from previous surgery
2 - Groin hernia incarceration
Clinical Features
Crampy, intermittent pain
Periumbilical or diffuse
Inability to have BM or flatus
N/V
Abdominal bloating
Sensation of fullness, anorexia
Physical Findings
Distention
Tympany
Absent, high pitched or tinkling bowel sound or “rushes”
Abdominal tenderness: diffuse, localized, or minimal

57. Bowel Obstruction Diagnosis Treatment Fluid NGT Analgesia
CBC and electrolytes
Electrolyte abnormalities
WBC >20,000 suggests bowel necrosis, abscess or peritonitis
Abdominal x-ray series
Flat, upright, and chest x-ray
Air-fluid levels, dilated loops of bowel
Lack of gas in distal bowel and rectum
CT scan
Identify cause of obstruction
Delineate partial from complete obstruction
Treatment
Fluid
NGT
Analgesia
Surgical consult
OR for complete obstruction
Peri-operative antibiotics

58. Case #6
48 yo obese F with one day hx of upper abd pain after eating, does not radiate, is intermittent cramping pain, +N/V, no diarrhea, subjective fevers. No prior similar symptoms.
Med hx: denies
Surg hx: denies
No meds or allergies
Social hx: no alcohol, tobacco or drug use

59. Case #6 Exam
T: 100.4, HR: 96, BP: 135/76, R: 18, O2 sat: 100% room air
General: moderately obese, no acute distress
CV: normal
Lungs: clear
Abd: moderately TTP RUQ, +Murphy’s sign, non-distended, normal bowel sounds
What is your differential and what next?

60. Cholecystitis Clinical Features Physical Findings
RUQ or epigastric pain
Radiation to the back or shoulders
Dull and achy → sharp and localized
N/V/anorexia
Fever, chills
Physical Findings
Epigastric or RUQ pain
Murphy’s sign
Patient appears ill
Peritoneal signs suggest perforation

61. Cholecystitis Diagnosis CBC, LFTs, Lipase
Elevated alkaline phosphatase
Elevated lipase suggests gallstone pancreatitis
RUQ US
Thicken gallbladder wall
Pericholecystic fluid
Gallstones or sludge
Sonographic murphy sign
HIDA scan
more sensitive & specific than US

62. Treatment
Surgical consult
IV fluids
Correct electrolyte abnormalities
Analgesia
Antibiotics
NGT if intractable vomiting

63. Case #7
34 yo healthy M with 4 hour hx of sudden onset left flank pain, +nausea/vomiting; no prior hx of similar symptoms; no fevers/chills. +difficulty urinating, no hematuria. Feels like has to urinate but cannot.
PMHx: neg
Surg Hx: neg
Meds: none, Allergies: NKDA

64. Case #7 Exam T: 37.9, HR: 110, BP: 150/90, R: 20, O2 sat: 99% room air
General: writhing around on stretcher in pain, +diaphoretic
CV: tachycardic, heart sounds normal
Lungs: clear
Abd: soft; non-tender
Back: mild left renal angle tenderness
Genital exam: normal
Neuro exam: normal
What is your differential diagnosis and what next?

65. Renal Colic Clinical Features
Acute onset of severe, dull, achy visceral pain
Flank pain
Radiates to abdomen or groin including testicles
N/V and sometimes diaphoresis
Fever is unusual
Physical Findings
non tender or mild tenderness to palpation
Anxious, unable to sit still

66. Renal Colic Diagnosis Urinalysis RBCs WBCs suggest infection CBC
If infection suspected
BUN/Creatinine
In older patients
If patient has single kidney
If severe obstruction is suspected
CT scan

67. Treatment
IV fluid boluses
Analgesia
Narcotics
NSAIDS
Follow up with urology in 1-2 weeks
If stone > 5mm, consider admission and urology consult
If toxic appearing or infection found
IV antibiotics
Urologic consult

68. Thank You